Medicare AdvantagePrior AuthHigh impact
Prior Authorization Changes for Some Commercial and Government Program Members
BCBS Texas·TX · Radiology, Sleep Medicine, Genetics +2 more·Prior Authorization
Effective date
Aug 1, 2026
We identified it
Jun 30, 2026
Summary
Blue Cross and Blue Shield of Texas is implementing prior authorization requirement changes for commercial and government program members, effective in two phases: October 1, 2026 for commercial members (adding radiology, sleep, molecular genetic lab, medical oncology, and drug codes to utilization management review) and August 1, 2026 for Medicare Advantage members (implementing Part B Step Therapy Program and adjusting code reviews). Billing teams must verify which utilization management vendor (Carelon, EviCore, or BCBSTX) handles each service type and obtain prior authorization accordingly.
Action Required
REQUIREMENTS:
By August 1, 2026: Billing team must update billing software and prior authorization workflows for Medicare Advantage members to implement the Part B Step Therapy Program requirements and reflect removal/addition of miscellaneous codes under BCBSTX review. Verify EviCore healthcare handles Part B Step Therapy reviews for MA members.
By October 1, 2026: Billing team must update prior authorization requirements for commercial members to route the following service categories to appropriate utilization management vendors:
- Radiology advanced imaging codes → Carelon Medical Benefits Management
- Sleep codes → Carelon Medical Benefits Management
- Molecular genetic lab testing codes → Carelon Medical Benefits Management (additions) and remove codes previously reviewed by Carelon
- Medical oncology codes → Carelon Medical Benefits Management
- Drug codes → BCBSTX
IMMEDIATELY: Front desk and billing staff must begin checking eligibility and benefits through Availity Essentials or preferred vendor BEFORE rendering any services to confirm current prior authorization requirements and applicable utilization management vendor. This step is mandatory and does not guarantee payment.
CONSEQUENCES: Services performed without required prior authorization or that do not meet medical necessity criteria will be denied for payment, and the rendering provider may not seek reimbursement from the member.